By Counterforce Health Team in Tepezza (teprotumumab) —

How to Get Tepezza (teprotumumab) Covered by Cigna in Michigan: Complete Appeals Guide with Forms and Timelines

Answer Box: Getting Tepezza (teprotumumab) Covered by Cigna in Michigan

Cigna requires prior authorization for Tepezza (teprotumumab) for Thyroid Eye Disease (TED). To get coverage: 1) Complete Cigna's Tepezza Prior Authorization Form with detailed TED documentation including Clinical Activity Score (CAS), 2) If denied, file internal appeal within 180 days, 3) Request external review through Michigan DIFS within 127 days of final denial. Standard review takes 5 business days; expedited available for urgent cases.

Table of Contents

Understanding Your Denial Letter

When Cigna denies Tepezza (teprotumumab), your denial letter contains crucial information that determines your next steps. Here's how to decode it:

Key Elements to Extract:

  • Denial reason code: Medical necessity, prior authorization missing, or plan exclusion
  • Appeal deadline: Typically 180 days for internal appeals with Cigna
  • Benefit type: Medical (J3241 HCPCS code) vs. pharmacy benefit
  • Required documentation: What Cigna needs to reconsider

Common Denial Codes for Tepezza:

  • Medical necessity not established: Insufficient documentation of moderate-to-severe, active TED
  • Prior authorization required: Treatment started without proper approval
  • Step therapy not met: Alternative treatments not documented as failed/contraindicated
  • Coding errors: Incorrect HCPCS J3241 billing or missing ICD-10 codes

Fixable Causes of Tepezza Denials

Many Tepezza denials can be overturned by addressing documentation gaps:

Missing Clinical Documentation

  • Clinical Activity Score (CAS): Must document CAS ≥4 for "active" disease
  • Severity markers: Lid retraction ≥2mm, proptosis ≥3mm, diplopia
  • Prior therapy failures: Corticosteroid intolerance or contraindications
  • Specialty care: Ophthalmologist or endocrinologist involvement

Coding and Billing Issues

  • Correct HCPCS: Use J3241 (10 mg units) for teprotumumab
  • ICD-10 codes: E05.00 (hyperthyroidism with eye involvement)
  • Administration codes: CPT 96365, 96366 for infusion services
  • Units calculation: Based on patient weight (10 mg/kg first dose, 20 mg/kg subsequent)

Administrative Oversights

  • Prior authorization timing: Must be obtained before first infusion
  • Provider network status: Ensure administering facility is in-network
  • Site of care: Cigna may require specific infusion settings

First-Level Appeal Strategy

Required Components for Cigna Appeals

Component Details Source
Appeal form Complete Cigna's standard appeal form Cigna Provider Portal
Medical records Complete TED documentation, CAS scoring Clinical notes
Prior therapy history Failed treatments with dates and outcomes Patient chart
Specialty consultation Ophthalmology/endocrinology notes Specialist records
Literature support FDA labeling, clinical guidelines FDA Access Data

Medical Necessity Letter Checklist

Essential Elements:

  • Patient demographics and diagnosis (ICD-10: E05.00)
  • TED severity documentation (CAS score, measurements)
  • Prior treatment failures or contraindications
  • Prescriber credentials and specialty
  • Clinical rationale citing FDA-approved indications
  • Weight-based dosing justification
Clinician Corner: Documentation Best Practices

Include specific measurements in your medical necessity letter: proptosis in millimeters, lid retraction measurements, and CAS components. Reference the FDA label which approves Tepezza for TED "regardless of activity or duration." This counters denials requiring "active" disease only.

Peer-to-Peer Review Process

Scheduling Your Call

  • Contact: Call 1-800-88-CIGNA (882-4462) to request peer-to-peer review
  • Timing: Request within 24-48 hours of denial notification
  • Preparation: Have complete patient file and supporting literature ready

Key Talking Points

  1. FDA indication: Tepezza is approved for TED regardless of activity or duration
  2. Severity documentation: Specific CAS score and clinical measurements
  3. Prior therapy: Document steroid failures, contraindications, or intolerance
  4. Urgency: Risk of permanent vision changes without treatment
  5. Guidelines: Reference American Thyroid Association recommendations

What to Expect

  • Duration: 15-30 minutes with Cigna medical director
  • Outcome: Approval, partial approval, or request for additional information
  • Timeline: Decision typically within 24-72 hours of call

Michigan External Review Process

If Cigna's internal appeals fail, Michigan residents have robust external review rights under the Patient's Right to Independent Review Act (PRIRA).

Timeline and Process

Step Timeline Action Required
Internal appeal completion First Must exhaust Cigna's internal process
External review request Within 127 days Submit to Michigan DIFS
DIFS acknowledgment 14 days DIFS notifies parties
Standard decision 56-60 days Independent medical review
Expedited decision 72 hours For urgent cases with physician attestation

How to File with Michigan DIFS

  • Online: DIFS External Review Form
  • Phone: 877-999-6442 (M-F, 8 AM-5 PM)
  • Mail: Michigan DIFS, Office of Appeals, P.O. Box 30220, Lansing, MI 48909-7720

Required Documentation

  • Cigna's final denial letter
  • Complete medical records supporting necessity
  • Physician's letter of medical necessity
  • For expedited review: Doctor's attestation of urgency
From Our Advocates

In our experience helping Michigan patients, those who file external reviews with DIFS within 30 days of their final Cigna denial—rather than waiting until the 127-day deadline—often see faster processing times. The independent medical reviewers appreciate having fresh clinical context and complete documentation upfront.

Appeal Letter Templates

Basic Appeal Letter Structure

[Provider Letterhead]
[Date]

Cigna Medical Director
[Address from denial letter]

RE: Appeal for Tepezza (teprotumumab) Coverage
Patient: [Name]
Policy: [Number]
Date of Service: [Date]

Dear Medical Director,

I am appealing your denial of Tepezza (teprotumumab) for my patient diagnosed with moderate-to-severe Thyroid Eye Disease (ICD-10: E05.00).

Clinical Summary:
• CAS Score: [Insert score] documented on [date]
• Proptosis: [measurement] mm (normal <21mm)
• Lid retraction: [measurement] mm
• Prior treatments: [List failed therapies with dates]

Medical Necessity:
Tepezza is FDA-approved for TED regardless of activity or duration. My patient meets all coverage criteria per your policy [reference specific policy section].

Supporting documentation attached:
• Clinical progress notes
• CAS assessment
• Prior treatment records
• Specialist consultation

I respectfully request immediate approval as further delay risks permanent vision impairment.

Sincerely,
[Physician name, credentials, NPI]

Tracking Your Case

Documentation Log Template

  • Date: Each interaction with Cigna
  • Contact: Representative name and reference number
  • Action: What was discussed or submitted
  • Follow-up: Next steps and deadlines
  • Status: Pending, approved, denied, appealed

When to Escalate to Regulators

Contact Michigan DIFS if:

  • Cigna misses appeal deadlines
  • Requests are ignored or lost repeatedly
  • You suspect bad faith denial practices
  • External review rights are denied

Michigan DIFS Contact: 877-999-6442

Boosting Your Win Rate

Evidence-Based Strategies

  1. Cite specific guidelines: American Thyroid Association, Endocrine Society recommendations
  2. Document contraindications: Why alternatives aren't suitable
  3. Include functional impact: Vision changes affecting daily activities
  4. Reference FDA labeling: Approved indications and dosing
  5. Provide comparative effectiveness: Why Tepezza is superior to alternatives

Common Mistakes to Avoid

  • Generic medical necessity letters
  • Missing CAS documentation
  • Inadequate prior therapy documentation
  • Delayed appeal filing
  • Incomplete supporting records

If Appeals Fail: Next Steps

Alternative Coverage Options

  • Formulary exceptions: Request tier reduction if covered at higher cost
  • Quantity limit appeals: If dosing restrictions apply
  • Site of care changes: Switch to preferred infusion location
  • Manufacturer support: Amgen By Your Side patient assistance
  • State insurance complaint: File with Michigan DIFS
  • Federal complaint: Contact CMS for Medicare Advantage plans
  • Legal consultation: Consider healthcare attorney for complex cases

About Counterforce Health: Counterforce Health helps patients and clinicians navigate insurance denials by creating targeted, evidence-backed appeals. Our platform analyzes denial letters and payer policies to draft point-by-point rebuttals that address specific coverage criteria, improving approval rates for complex medications like Tepezza.

FAQ

How long does Cigna prior authorization take for Tepezza? Standard review is 5 business days. Urgent cases can be expedited with physician attestation of medical urgency.

What if Tepezza is non-formulary on my Cigna plan? Request a formulary exception through Cigna's standard process, providing medical necessity documentation and prior therapy failures.

Can I get expedited appeals in Michigan? Yes. Michigan DIFS offers 72-hour expedited external review for urgent cases with physician certification that delay would harm the patient.

Does step therapy apply to Tepezza? Many Cigna plans require documentation of corticosteroid failure or contraindication before approving Tepezza.

What's the success rate for Tepezza appeals? While Cigna doesn't publish specific statistics, well-documented appeals addressing the exact denial reason have significantly higher success rates.

How much does Tepezza cost without insurance? Current wholesale cost is approximately $17,511 per 500mg vial, with full treatment courses often exceeding $350,000-$500,000 depending on patient weight.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Consult your healthcare provider and insurance plan documents for specific guidance. For assistance with insurance appeals, contact Counterforce Health or Michigan DIFS at 877-999-6442.

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